Second Report of the Structured Chronic Disease Management Programme in General Practice

The HSE published the second review into the implementation of the Structured Chronic Disease Management (CDM) Programme in General Practice on Wednesday 22nd March 2023. 

The report focuses on the first two years of implementation from January 2020 to January 2022. It largely describes a population aged 65 years and over due to the age-based phased introduction of the programme and it aims to reach full implementation in 2023.

Key Information:

• 91% of patients with chronic disease were not attending hospital for the ongoing management of their chronic condition, which was now fully managed routinely in primary care
• 91% of General Practitioners signed up for the CDM contract
• 83% of eligible patients (65 years and older) enrolled 
• Around 800,000 reviews have been carried out by GPs and practice nurses
• Improving trend self-reported lifestyle risk factors - 13% of patients had given up smoking between first and third visit; of patients who were obese at their first visit, 1% of these had achieved normal weight and a further 13% of them had reduced weight and are now be in the overweight category rather than obese.

This reports refers to patients treated by GPs for the first two years of the programme and comprises 186,210 patients in total. It focusses particularly on patients (43,600) who have had at least three reviews in the first two years of the programme to describe trends in outcomes.

The report's major findings include:

Multi-morbidity

It is extremely encouraging to note that the vast majority of multi-morbidity patients did not attend hospital for the routine management of their chronic conditions and their conditions were reported as being fully managed routinely in Primary Care.

• Multi-morbidity increases with age (defined as two or more chronic conditions); 51% of over 85 year olds had two or more chronic conditions compared to 42% of the cohort overall
• 20% of over 85 year olds had three or more chronic conditions compared to 14% of the cohort overall
• Patients with heart failure tend to have more comorbidities than patients with other chronic conditions e.g. 87% of heart failure patients have at least 1 other chronic condition.

Lifestyle Health Behaviour Improvements

The report shows improvements in all the modifiable risk factors concerned between the first and third visit, including patients who had higher risk profiles at the first visit.

• Of those that were smokers on their first visit 13% had become non-smokers by their third visit
• Of those who were obese at their first visit 1% had achieved normal weight and 13% had reduced weight to be in the "overweight" category by their third visit
• Of those who had inadequate physical activity on their first visit there was a 48% reduction by the third visit and 30% had achieved adequate levels by their third visit
• Of those who had risky alcohol behaviour (Audit C Scale) on their first visit 67% had become either normal drinkers or were non-drinkers by their third visit.

Bio Metric Risk Factor Improvements (Medical)

There is an improving trend in in biometric measurements such as blood pressure, LDL cholesterol and HbA1c, over time in this cohort.

• Both systolic and diastolic blood pressure had dropped by 1 mm Hg for the whole cohort of patients who had three visits to their GP. (This population scale reduction is linked to very significant reductions in future CVD events i.e. reduction in heart failure of 13.3, in Coronary Heart Disease of 9, and in stroke a 4.8 events per 100,000 person years).

Blood test results

The Chronic Disease Treatment Programme requires a series of blood tests to be carried out at specified intervals, some in common across all conditions and some specific to the condition concerned. Overall the results for LDL (low-density lipoprotein) cholesterol show important improvements against target for all sub categories, between their first and third visit to their doctor, indicating a raised awareness among doctors and patients and tighter control either by diet or medication in combination.

Patients with Diabetes also showed important improvements against their targets for Hba1C levels.

Diabetic Foot Examinations

Diabetic foot disease is a major cause of hospital admission and surgery for diabetic patients, hence early identification and management is essential. The Chronic Disease Treatment Programme requires the GP or the Practice Nurse to carry out a number of tests on diabetes patients' feet to identify foot complications.

• 98% of diabetic patients had a detailed foot examination
• 21% of diabetic patients had an abnormal foot exam and should be continued to be monitored twice yearly, and referred to the ambulatory care hub podiatry service if necessary. 

Healthcare

The CDM programme requires that General Practitioners develop, discuss and record a care plan with each of their patients and that this plan is updated at each visit. The care plan includes anticipatory care, recommended actions for when the patient deteriorates and facilitates the development of patient-centred goals for treatment and behaviour change to be agreed and documented between patient and their GP. 

• 53% (i.e. 98,494) of patients had a comprehensive patient centred care plan by January 2022, this had risen to 71% of patients by January 2023. 

Hospital attendances

GPs participating in the Treatment Programme are asked to indicate whether their patients are also attending hospital for the care of each of the chronic conditions included in the Treatment Programme. A major objective of the Chronic Disease Management Programme and the Enhanced Community Care programme is to enable patients to be managed in primary care as much as possible.

• 91% of patients with chronic disease were not attending hospital for their chronic condition, which was now fully managed routinely in primary care.

The full report is available on the HSE website here.